PacificSource Health · Heart Disease Risk Reduction

PacificSource Health coverage for Ozempic (Heart Disease Risk Reduction)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Diagnosis documented with a code
Established cardiovascular disease
Lab results confirming eligibility

Qualification pathways

You can qualify through any one of these.

T2DM with Cardiovascular Disease (FDA-approved indication)

All of:

Diagnosis of Type 2 diabetes confirmed with lab testing
Diagnosis of cardiovascular disease
No concurrent use of other GLP-1 receptor agonists
Not using for weight loss or other excluded diagnosis

Documentation to bring

Lab confirmation of Type 2 diabetes diagnosis
Documentation of cardiovascular disease diagnosis
Claims history and ICD-10 codes reviewed

Approval and renewal

Initial approval: 24 months
Renewal: every 24 months
To renew, the plan looks for Documentation of disease responsiveness to therapy required at reauthorization.

Not covered when

Use for weight loss or other excluded diagnosis
Concurrent use of other GLP-1 receptor agonists
History of ketoacidosis

Policy note: Covered as FDA-approved indication 'T2DM and cardiovascular disease'. Policy does not exclude T2DM patients for this indication — this is distinct from Wegovy's CV indication which does not require T2DM.

Policy effective June 22, 2026 · verified June 10, 2026 · source: cw577pv8jf

ACA Marketplace